Lake County

Public Health Assessment and Wellness

Alameda County - Food to Families (A Kresge Foundation grant)

State: CA
Type: Model Practice
Year: 2013

ABSTRACT:

Food to Families (F2F) is an innovative partnership project, funded for three years by the Kresge Foundation, with overarching goals to 1) transform the food landscape 2) to provide local economic and employment opportunities for young adult residents, and 3) to reduce the risk of obesity and overweight in West Oakland (WO) and Ashland-Cherryland (A-C).

In a 2007 WO youth survey, 79% reported that lack of activities for youth was a major concern. Additionally, 77% reported that the lack of jobs for young people was a concern (OYM, 2007). In a community-wide survey conducted in 2007, improved and connected youth services and employment continued to be a top priority for changes residents wanted for their neighborhood (CAPE, 2007). Our innovative model meets two community-expressed needs, while improving community health and increasing access to healthy food. Existing data confirms that WO and A-C are indeed “food deserts” lacking affordable fruits and vegetables and other foods that comprise a healthy diet; in addition, each are home to around three dozen liquor and corner stores, and experience some of the highest rates of overweight, obesity, and weight-related chronic disease in the county.

ORGANIZATION:

Alameda County Public Health Department

TITLE:

Alameda County - Food to Families (A Kresge Foundation grant)

Food to Families (F2F) is an innovative partnership project, funded for three years by the Kresge Foundation, with overarching goals to 1) transform the food landscape 2) to provide local economic and employment opportunities for young adult residents, and 3) to reduce the risk of obesity and overweight in West Oakland (WO) and Ashland-Cherryland (A-C). In a 2007 WO youth survey, 79% reported that lack of activities for youth was a major concern. Additionally, 77% reported that the lack of jobs for young people was a concern (OYM, 2007). In a community-wide survey conducted in 2007, improved and connected youth services and employment continued to be a top priority for changes residents wanted for their neighborhood (CAPE, 2007). Our innovative model meets two community-expressed needs, while improving community health and increasing access to healthy food. Existing data confirms that WO and A-C are indeed “food deserts” lacking affordable fruits and vegetables and other foods that comprise a healthy diet; in addition, each are home to around three dozen liquor and corner stores, and experience some of the highest rates of overweight, obesity, and weight-related chronic disease in the county.
Alameda County has a population of 1,510,271 as of April 2010. Both West Oakland and Ashland-Cherryland have a population estimated at approximately 25,000 residents. Data indicates that over half of adults in Alameda County are overweight or obese, including 46% of adult females (ACPHD, 2010). Recent reviews of medical charts of pregnant women receiving perinatal services in WO and A-C demonstrate that a high proportion of these women are overweight or obese, with subsequent pregnancies contributing to prenatal weight and postnatal weight retention. In 2008-2009, Oakland’s school district tied for third highest in the percentage of students that were overweight (36.4%) and the San Lorenzo school district serving A-C was rated seventh (31.4%) (CDE, 2005-2006). A-C has the third highest rates of diabetes and highest rates of all-cause mortality in the county (ACPHD, 2010). Oakland has the fourth highest diabetes rate and the third highest rate of all-cause mortality, countywide (ACPHD, 2010).
F2F will not only benefit pregnant women receiving clinical care, but impact the health of their families and the community as a whole by creating new resources, fresh food access points and raising awareness. To accomplish this, the Alameda County Public Health Department (ACPHD), its Nutrition Services (NS)program and the Building Blocks Collaborative (BBC) support the work of unique, unlikely alliances: two nonprofit organizations serving high risk youth and two federally qualified health centers (FQHC's). Partners in WO are Mandela Marketplace (MMP) and the West Oakland Health Center (WOHC). In A-C, partners are the Deputy Sheriff's Activities League's Dig Deep Farms and Produce (DSAL/DDFP) and Tiburcio Vasquez Health Center (TVHC). F2F aims to address community-expressed need for local access to healthy food and employment/economic opportunities for youth. These needs emerged through community engagement processes supported by community data. As a result, F2F developed interventions that continue to address these needs today. The first is Produce Rx, a clinic-based program to provide pregnant women with produce “prescriptions” connecting them with local food access points and consumer training developing skills around food purchase, preparation, storage and healthy life skills. The second is Team Fresh, a training program supporting young adult-led development and implementation of produce supply businesses.
Major activities include: annually, 30 pregnant women at each FQHC in WO and A-C participate in Produce Rx, receive a produce prescription and a variety of classes with a cooking/nutritional education component; Team Fresh in WO and A-C are recruited, trained and supported to lead sustainable produce supply businesses; BBC partners support F2F efforts through submission of mini-grant proposals. The public health impacts are
1. Pregnant women and their families will report an increase in their weekly consumption of produce
2. Pregnant women and their families will have increased access to fresh produce as a result of Produce Rx.
3. Young adults in WO and A-C increase their leadership and job skills by Team Fresh participation.
Successes to date include strong partnerships between community-based organizations, the FQHC’s, and the LHD; enhanced interventions; good participation by pregnant women and their families; the creation of one model adapted to serve two different communities; integration of young adults into staffing of partner organizations. Greater detail is provided in the evaluation section. F2F is receiving $750,000 over 3 years from the Kresge Foundation and additional in-kind support from ACPHD. F2F began implementation in January 2011 and is in the second project year.

ResponsivenessThe public health issue this practice addressesOne of the F2F strategies is to reduce the risk of overweight and obesity among pregnant women receiving perinatal services at the FQHC's through transforming the food and economic landscape in WO and A-C. Overweight and obesity is a significant public health concern in Alameda County, particularly among women of child-bearing age in low-income neighborhoods. Data confirms that WO and A-C experience the highest levels of obesity and overweight and related morbidity and mortality in Alameda County. Overweight and obesity during pregnancy carries risks for both mother and child, including later-life obesity, chronic pulmonary disease, cancer, depression, drug abuse and mental health problems, and cardiovascular disease (Shonkoff, 2009). A recent study confirms that the greater a woman’s weight gain during pregnancy, the higher the risk that her child will be overweight by age three, and evidence shows this continues into adolescence and adulthood (Murphy Paul, 2010). Addressing overweight and obesity among pregnant women has the potential to improve health in the immediate and long-term.
Health inequities, like chronic disease rates, are a result of conditions of social, economic and political inequality that result in inequitable distribution of the resources that affect individual and population health (ACPHD, 2008). Therefore, a woman’s risk of overweight or obesity, while associated with her health behaviors, is affected by the context in which she lives. A-C and WO experience high rates of poverty, unemployment, and resource deficient schools, factors that contribute to and perpetuate disparities. In 2006, in WO over 50% and in A-C 47% of mothers were receiving Medi-Cal, a recognized indicator of poverty. Residents of A-C experience unemployment rates that are persistently higher than that of the county. Only 73% of Ashland residents and 67% of Cherryland residents have a high-school diploma or higher, compared to 86% for the county (ACS, 2006-2008). As a result of inequities, WO and A-C lack access to healthy food and experience persistent economic underdevelopment, factors related to higher rates of overweight and obesity. A cycle of persistent neighborhood poverty and lack of economic development have resulted in WO and A-C becoming “food deserts.”Process used to determine the relevancy of the public health issue to the communityThe planning process for Food to Families (F2F) brought together individuals and organizations that understand the needs of the target neighborhoods and who currently participate in community-based, health and social change movements. To ensure a broad base of voices and perspectives were included at each stage of planning, we received input and guidance from residents in various settings collaborating with community representatives who work directly with residents in WO and A-C. Residents included neighborhood program participants, such as youth in the Deputy Sheriff’s Activities League (DSAL), community health workers in the Improving Pregnancy Outcomes Program, and members of civic engagement groups, such as the WO Resident Action Council and the A-C Eden Area Livability Initiative. Building Blocks Collaborative (BBC) partners work in public agencies and community-based organizations in WO and A-C and are community residents themselves. These diverse BBC partners were involved throughout the entire planning and community engagement process and provided valuable insight throughout an intensive, two month period.
In addition, the Alameda County Public Health Department (ACPHD) employed a resident advisor from WO who was an active on the BBC and F2F planning team and provided guidance on resident outreach. Meetings informed the development of our model with these individuals and organizations and by summaries from community surveys. By consulting multiple sources of expressed community voice, we were able to identify the lack of access to healthy food and lack of youth employment and economic opportunities as the most notable health-related concerns among residents. Meetings with community residents and representatives then focused on how F2F could address both of these community-expressed needs. After each of these meetings, our planning team analyzed the predominant themes making adjustment to our model prior to meeting with the next group. The result is a model that addresses expressed community need, builds upon existing community initiatives and momentum, and utilizes BBC partner strengths and assets. ACPHD and the partners continue to share F2F work with the community through communication channels that each organization or partner employs which is discussed in the collaboration section.
How the practice addresses the issueRecognizing that the lack of stores that sell healthy foods is related to the obesity and overweight and the lack of economic opportunities in the communities, F2F implements two interventions that address these needs. The first is Produce Rx, a clinic-based program to provide pregnant women with produce “prescriptions” that connect them with local food access points and produce consumer trainings that assist them to develop food purchase, preparation and storage skills. The second is Team Fresh, a job-training program to support young adult-led development and implementation of produce supply businesses. In a 2007 WO youth survey, 79% reported that lack of activities for youth was a major concern and 77% reported that the lack of jobs for young people was also a concern (OYM, 2007). In a community-wide survey conducted in 2007, improved and connected youth services and employment continued to be a top priority for changes that residents wanted for their neighborhood (CAPE, 2007). This innovative model meets two community-expressed needs, while improving community health and increasing access to healthy food.
Innovation Evidence based strategies used in developing this practiceF2F expands on both food access intervention models and nutrition education best practices. Currently, nutrition education is part of clinical care for pregnant women in California. Communities in San Francisco, Boston, Baltimore, Los Angeles, and Honolulu (Hoffman et al., 2009; Gittelsohn et al., 2009; Gittelsohn et al., 2010; Azuma et al. 2010) are model programs for efforts to encourage corner stores to sell healthy foods. Although not directly used in developing the model, F2F does address one of the CDC's Winnable Battles--Nutrition, Physical Activity, and Obesity. By increasing the number of food access points, creating and sustaining employment and job training opportunities for youth, and working with pregnant moms, F2F takes an environmental approach to creating pathways for communities to make healthier informed choices and live productive lives.
The practice is new to the field of public health
Process used to determine that the practice is new to the field of public healthThe application and subsequent recognition as one of eight nationally accepted projects by the Kresge Foundation affirmed F2F as new to public health. F2F focuses on health equity and utilizes innovative, unlikely alliances bridging issues of food access and economic/youth development practices. F2F employs the strategic coupling of environmental, community-level intervention with a behavioral, individual-level intervention to successfully improve the health status of a community. Core partners include Mandela Marketplace, Deputy Sheriffs’ Activities League, West Oakland Health Council and Tiburcio Vasquez Health Center. Mandela Marketplace (MMP), a community leadership incubator, provides civic engagement and economic opportunity to low-income residents and underrepresented farmers. They pioneer the development, application and assessment of community food systems.
Their Healthy Neighborhood Stores Alliance has begun piloting youth-led food enterprises in West Oakland. Mandela's executive director, Dana Harvey, was named a 2012 White House Champion of Change for Food Security. The Alameda County Deputy Sheriff’s Activities League (DSAL) provides recreational and leadership opportunities investing in high-risk youth in A-C to combat recidivism, and oversees DDFP, a project building sustainable local food economy while creating entrepreneurial opportunities for high-risk youth. Dr. Henry Richard Herrera, DDFP’s farm manager, is 2012 recipient of the Catherine Cowell Award by the American Public Health Association, Food and Nutrition Section recognizing his work in public health nutrition. Tiburcio Vasquez Health Center (TVHC) and WO Health Council (WOHC) are both recognized Federally Qualified Health Centers and regional leaders in integrated and holistic community health services.
How this practice differs from other approaches used to address the public health issue F2F is innovative because of the coupling of environmental, community-level intervention with a behavioral, individual-level intervention to successfully improve the health status of a community. F2F accomplishes this through its economic development strategy of increasing leadership and creating employment opportunities for young adult community residents through creating fresh produce access points. The "Story of Jay" in A-C exemplifies this. DSAL and DDFP works with youth impacted by the juvenile justice system many of whom may have been formerly incarcerated. "Jay" is the coordinator for a produce farm and orchard on land above the Camp Sweeney Juvenile Detention and Education Center in the A-C area. He was also formerly incarcerated. Although anecdotal, DDFP farm manager shared that by keeping him employed, local government saves approximately $65,000 annually (http://www.lao.ca.gov/laoapp/laomenus/sections/crim_justice/2_cj_county_spending.aspx?catid=3). Jay is valued and an integral part of DDFP operations. Through DDFP and Jay's commitment to the local, urban gardening program, pregnant and parenting moms seen by Tiburcio Vasquez Health Center in A-C are able to receive and access plentiful CSA deliveries.

Local Health Department and Community CollaborationPrimary StakeholderThe primary stakeholders are the F2F partners: Mandela Marketplace, the Deputy Sherriff’s’ Activities League's Dig Deep Farms and Produce, West Oakland Health Council , Tiburcio Vasquez Health Center; the LHD: the Alameda County Public Health Department , its Nutrition Services (NS) program and the Alameda County Building Blocks Collaborative (BBC). Neighborhood residents and local policy-makers are also important F2F stakeholders.LHD RoleF2F is led by the Alameda County Public Health Department as part of our county-wide collaborative effort, the BBC. Convened by ACPHD, BBC is a partnership of multi-sector community and governmental organizations. As a collaborative comprised of diverse stakeholders, we bring a wide range of expertise and perspectives to the F2F Initiative. The BBC has been in existence since September 2009 and meets monthly to cultivate learning and dialogue around health inequities and plan for continued collaborative action. We recognize that multiple sectors – healthcare, community, physical and economic environment, and education – influence health across the life course.
The ACPHD is a national leader in promoting health equity through community-based programs and policy advocacy, in partnership with community residents and organizations. F2F resides within the Nutrition Services program of ACPHD bringing advisory services with regards to program and policy expertise in nutrition education, physical activity and health and wellness as a whole. F2F also maintains strong linkages with staff of the ACPHD Office of Director and Community Assessment Planning and Education (CAPE) unit, which leads data collection and program evaluation for F2F. Our F2F core partners, who are members of BBC, are well poised to work on increasing pregnant women’s access to healthy food. They bring expertise in perinatal services, community development, local food systems, entrepreneurship and youth employment training, and community organizing.Stakeholder/PartnersF2F was created collaboratively. Four core partners (described above) were integral in the creation of the grant and are currently implementing the F2F program plan. In West Oakland, Mandela Marketplace implements the youth based service delivery model. Young adults are employed holding leadership roles in communicating with Healthy Neighborhood Store Alliance owners who are points of access for the pregnant/parenting moms from the FQHC partner, the West Oakland Health Council. In Ashland-Cherryland, the Deputy Sheriff Activities League’s Dig Deep Farms and Produce employ young adults who insure ample food production and supplement produce boxes with produce from other local farmers to deliver to moms who are patients of the Tiburcio Vasquez Health Center and participants in F2F.
Through continuous communication and assessment processes, these partners insure relevancy and timeliness of services to the moms. The partners work towards fulfilling the overall goals. The LHD, ACPHD, employs two staff, namely a project manager and evaluator, to ensure that implementation is progressing, to provide technical assistance to partners, and to evaluate process and outcome indicators. ACPHD staff in the Office of the Director, the CAPE unit, and NS leadership provide in-kind, advisory support. Specifically, a special project manager serves as one of the primary advisors and liaisons to the BBC, the membership body in which F2F was conceived. F2F progress is reported at the semi-monthly BBC meeting and to the BBC steering committee monthly. F2F partners are in regular communication with the project manager and evaluation team and meet on a quarterly basis with on-site visits as needed. As ACPHD is responsible to the Kresge Foundation regarding the outcome of the grant, the Director of ACPHD has the ultimate authority to approve or disapprove changes to the grant.As the LHD, ACPHD convenes both the BBC (described above) and the four F2F partners. ACPHD co-created the project that builds directly on existing community momentum focused on food justice, youth and local economic development. BBC member agencies aligned with F2F principles and the BBC Bill of Rights also have the opportunity to collaborate with other member agencies the spirit of collaboration. ACPHD views itself as partners with the community and fosters linkages with community stakeholders. Furthermore, the F2F project manager with support of the NS director, convenes the Alameda County Obesity Prevention Partnership that is similarly aligned with F2F principles working towards
1) equal access to informed health care (both clinical and community) and healthy (affordable) food and beverages, 2) healthful, safe and transportation friendly environment for families to access physical activity such as outdoor spaces, and 3) pathways to support feeling happy and healthy and safe for low-income Alameda County residents.
These collaborations are natural pathways to share the core work of the F2F partners while also resourcing the program through such connections.Lessons LearnedThroughout the first year, unanticipated collaborative challenges were experienced. It took longer than expected to fully roll out F2F, partially due to the difficulties in collaborating with multiple partners in different geographic areas. Varying levels of the four organization’s leadership were involved in the actual grant creation, not necessarily those that are now implementing the grant. As a result , it took considerable time for the partners to have a mutual understanding of the grant and deliverables. Moreover, the partners in West Oakland and Ashland-Cherryland had not worked together previously and it took time to create trust and to allow space to fully embrace all aspects of the grant with each other. As the second year approached, F2F leadership addressed this challenge through close oversight and enhanced communication efforts. In year two, ACPHD conducts frequent site visits, and quarterly meetings that include facilitated conversation starters and opportunities for dialogue between and amongst the stakeholders so programmatic, institutional and systemic views are addressed and expressed. With the implementation of the mini-grants, the positive lesson learned is that the BBC continues to champion F2F principles through innovative cross collaborations.
Implementation StrategyAs previously described, goals, objectives and activities were determined collaboratively Annually, ACPHD andF2Fcorepartnersdevelop scopes of work contracting with the partners delineating specific activities. Overarching goals remain the same: to transform the food landscape, to provide local economic and employment opportunities for young adults of WO and A-C, and to enhance perinatal clinical services connecting women to the improved food environment. Objectives are as follows:
1. Pregnant women and their families will report an increase in their weekly consumption of produce2. Pregnant women and their families will have increased access to fresh produce as a result of participating in Produce Rx. 3. Young adults in WO and A-C will increase their leadership and job skills by participating in Team Fresh.
Annually, a minimum of 30 pregnant women at each FQHC participate in Produce Rx. F2F core partners develop materials and clinical protocols for Produce Rx, which include produce consumer trainings; a produce “prescription”, a list of recommended seasonal produce, an easy-to-cook recipe, and a food access resource guide (e.g. corner stores, farmers markets, etc.).Produce Rx was successfully piloted and is currently operating.
Annually,60 pregnant women will receive a produce “prescription” at each trimester visit during their nutrition assessment and 60 pregnant women will attend at least one of the bi-monthly produce consumer trainings offered at WIC sites on topics such as shopping for produce on a budget, cooking fast, health meals, or storage of fresh produce. Staff at FQHCs in WO and A-C conduct nutrition assessments with each pregnant woman during their trimester visits. Produce-purchases of the 60 women receiving coupons are tracked throughout pregnancy using a coupon tracking system.
Team Fresh youth are recruited, trained and are supported in leading sustainable produce supply businesses. Ten young adults in each neighborhood are identified to become part of a Team Fresh. They receive training on health, sustainable food systems, community development, and other related topics. Team Fresh works in conjunction with the FQHCs to develop and distribute the food resource guide for the Produce Rx. Team Fresh also conducts business assessments in their local areas in preparation to enhance their produce supply business.These tasks are ongoing and are revisited on a monthly as well as quarterly basis by partners. We are in the second year of implementation of the three-year grant period.For effective and consistent program implementation, partners work collaboratively as follows:
1) ACPHD works collaboratively with F2F core partners to create work agreements. 2) Agreements are discussed and reviewed with LHD stakeholders for formal approval. 3) Contract agreements are created outlining deliverables in scope of work. 4) Stakeholders are informed of progress through designated staff liaisons and receive and discuss monthly and/or quarterly updates via phone, in person meetings or during on-site visits 5) F2F partners, project staff and advisors share and discuss successes and challenges at bi-monthly Building Blocks Collaborative meetings 6) Convene and conduct quarterly all team meetings in which technical assistance may be provided. Throughout the year, staff may conduct assessments as needed to collect information from partners and participants to inform programmatic or structural changes as needed.
Lessons LearnedAs mentioned earlier, start up of F2F took longer than expected to fully roll out. Through this experience, we continue to practice and learn that ongoing communication and responsiveness is highly critical for effective program implementation. Partners involved are aware that that stages of group development –forming, storming, norming, performing – can occur in different iterations. Throughout time, the partners gain more trust in the process and each other. Once agreements and timelines are determined, this helps to work through subsequent misunderstandings or disagreements.
In year one, a charter was created that is still referred to during times of uncertainty. As we approach year three of project implementation, we are able to have focused, forward thinking conversations using a guided tool coined by our evaluation team – CESR - collaboration, evaluation, sustainability, and replicability.Cost of ImplementationFood to Families is a three-year initiative supported by a $750,000 Kresge Foundation Safety Net Enhancement Initiative grant. ACPHD provides an estimated $200,000 in in-kind costs per year in support of the initiative.

Food to Families is pursuing both process and outcome evaluation. The process evaluation documents activities, determines fidelity to the original model, and assesses successes, challenges and lessons learned. Program partners have used process evaluation information to reflect on the first year of the project, and to make mid-course corrections in both program implementation and data collection strategies. The outcome evaluation determines whether Food to Families is changing pregnant women’s access to and intake of fresh produce, and their ability to maintain a healthy weight during pregnancy. The F2F evaluation approach is participatory, meaning that the four main partners have been involved in multiple phases of the evaluation, including: choosing process and outcome measures; assisting with data collection and interpreting findings.
The primary goals of F2F are: 1. Pregnant women and their families will report an increase in their weekly consumption of produce as a result of having increased access to fresh produce 2. Pregnant women and their families will have increased access to fresh produce as a result of participating in Produce Rx. 3. Young adults in West Oakland and Ashland-Cherryland will increase their leadership and job skills by participating in Team Fresh.
Objective 1. As a result of participating in the F2F Produce Prescription Program, pregnant women and their families will have increased access to and intake of fresh fruits and vegetables. The F2F process evaluation tracks enrollment, return visits and pre-pregnancy body mass index with a standardized intake form. Program staff document the number of women attending nutrition education classes and receiving coupons or free deliveries of fresh produce. WOHC tracks redemption of produce coupons with business owners at redemption sites. Women’s views about F2F, including satisfaction with classes, F2F coupons and produce they receive is assessed through phone surveys and focus groups. Health educators help assess access to fresh produce during regular pregnancy check-ups at each trimester through a multiple choice questionnaire and 24-hour food recall. Indicators of food access include: whether participants have increased knowledge of how to choose and store fresh produce; intention to cook with it; perception that fresh produce is available to them locally and change in number of servings of fresh produce eaten per day. The process evaluation found that F2F met its objectives for the number of women enrolling in the program (30) at each site, and continuing their participation (2 or more visits).
In WO, 72 women enrolled initially, and 36 had 2 or more visits. In A-C, 37 women enrolled, and 23 came to 2 or more visits. Both sites served women who were overweight and obese, as planned. To reach enrollment objectives, and both sites decided to serve some women (about 1 in 4) who were under or normal weight, who also needed access to fresh produce. An initial assessment in spring 2012 found that the number attending nutrition classes was lower than expected at each site. Following program changes, more women had participated by fall (about 20 at each site, attending an average of about 3.25 classes each). The number receiving coupons was also lower than expected in WO, due to an initial plan to distribute them at classes, rather than at their clinic visits at each trimester. Through staff observation, phone surveys and focus groups, several barriers for attending classes and redeeming coupons were identified, including transportation needs and feeling unsafe on the street or at the corner store. Preliminary outcome evaluation found increases in some indicators of access to and intake of fresh produce. In A-C, there was a small increase in the percentage who felt it easy to find affordable, fresh produce in their neighborhood. In WO, 29% of participants began shopping for produce at their corner store, a marker of greater access. According to Food Recall data, A-C met its objective for 60% of participants to increase their intake of fresh produce. Of the 23 women for whom there was data, 14 (61%) increased, 6 (26%) decreased and 3 (13%) stayed the same. Average increase and decrease was 2.5 portions. Analysis didn't find increases in intention to cook with fresh produce and knowledge choosing ripe and good-tasting produce, which were already high at pre-test. There was insufficient data to determine whether produce intake had changed for WO participants. It is still unclear whether these changes in access and intake were due to the program, since the number of participants was relatively small, and without a comparison group. F2F program evaluators presented results to partners as it became available, leading to changes in program implementation and data collection strategies.
Data revealed a need to clarify the process objective for participation, which was originally defined as the number enrolling in the program. Due to pregnancy loss and other losses to follow-up, F2F decided to aim for 30 women to make a second or third visit to the program. Looking at the pre-pregnancy BMI, partners reiterated the benefit of offering the program to all women, not just those who were overweight or obese. The low numbers participating in nutrition education classes at both sites prompted change. For example, A-C offered their classes at new times, while WO began providing more incentives and free transportation. They also added a new coupon redemption site at an urban farm. While presenting the F2F results to staff, the evaluators received feedback about several missing elements in the data collection, including whether the women had received produce deliveries or redeemed their coupons, and how much of the produce they subsequently consumed. The evaluators added these questions to the clinic visit questionnaires. The outcome data further highlighted the need for a comparison group to see whether F2F women were eating more fruits and vegetables than comparable populations.
Objective 2. Participating pregnant women will maintain a healthy weight gain during pregnancy. A “healthy weight gain” for each participant was defined as staying within a range based on their pre-pregnancy Body Mass Index (guidelines from the Institute of Medicine). The program logic model seeks to link this outcome to the process measures on intake and access to fresh produce, as defined in the previous section.
In A-C, 18 (78%) out of 23 participants had “appropriate weight gain” for their pre-pregnancy BMI based on the IOM’s guidelines. Appropriate weight gain for WO was unable to be calculated due to problems with data collection in WO and insufficient numbers of women returning for a follow-up visit. While many women in WO did get seen multiple times, WO data entry was inconsistent .. In doing these calculations, we realized `that we should also be computing gestational age – since women gain the most weight during the last weeks of their pregnancies. In other words, weight gain at week 30 can be more than 10 pounds different than a woman at week 40 of her pregnancy.
F2F partners provided feedback about the data. They were pleased that the data appears to be on-track. The concern about gestational age was addressed and it is a possibility to add date of visit and due date to the database to address this. We also discussed post-partum weight loss as a more appropriate metric, especially 6-months post-partum. Alameda County WIC could possibly provide data for comparison.Objective 3. Young adults in West Oakland and Ashland-Cherryland will increase their leadership and job skills by participating in Team Fresh. F2F tracked the process objectives of number of youth hired by Mandela Marketplace (MMP) and Dig Deep Farms and Produce (DDFP). The outcome evaluation delved into the types of skills developed by the youth, and the meaning of the program to the participants through qualitative methods – participant observation (written into blog entries), one-on-one interviews and focus groups. Program records show that 6 youth participated in the WYSE team during the first year of F2F, and an additional 3 in the second year. A focus group in the middle of the first year assessed the impact of West Oakland Youth Standing Empowered (WYSE) on participating youth, particularly in the areas of leadership and development of personal and professional skills.
The main focus group questions were about development of leadership and business skills. To better understand the impact of WYSE on the participants, questions were added to explore development of interpersonal and personal skills, and how the youth feel WYSE has made a difference for themselves, peer, families and community. The evaluator analyzed the interview transcript for major themes, with the assistance of the F2F Program Manager. According to the focus group, members of the WYSE team have increased their skills in business practices, leadership, communication and conflict management. Further, they developed pride in their work, and accountability to each other. Through trainings with nutritionists, they learned about healthy eating, which prompted them to change their own behaviors, and to influence family members to do the same. Along with benefitting the members, WYSE has had a positive impact on the West Oakland community. WYSE youth felt that they had helped change the WO food environment, by making local, affordable, fresh produce more available to residents, including pregnant women in the F2F program. They have also helped their community by developing mentoring relationships with younger youth, working on urban gardens and advocating for food access to policy makers.According to program records, 5 youth were employed by DDFP. They were trained on a variety of topics, including food cultivation, business practices and fiscal management. An intern and the F2F evaluator gathered information about the DDFP youth program from a focus group and several one-on-one interviews. Five out of six DDFP employees participated in the focus group. The ACPHD intern interviewed three DDFP employees individually during three occasions. Under the direction of the F2F evaluator, the intern analyzed the information gathered from the focus group and interviews to find common themes, and drafted a report. The research found that employees were receiving benefits from the program in many areas of their lives. Employees have gained business and technical skills that are transferable, including managing logistics, customer service and leading a team. They are serving in leadership roles, developing personal skills and hope for their futures. In addition, they are changing their own eating habits, and those of the community. The focus group reports for WYSe and DDFP were given to each F2F partner. The programs have used these results to explain the program and what it means to the community and funders. Results from qualitative assessments were also shared through a blog entry about DDFP employees, which was published on the Alameda County Building Blocks Collaborative website(http://buildingblocksalamedacounty.wordpress.com/).

Stakeholder CommitmentF2F stakeholders are committed to sustaining the program and services. Partners have begun to articulate how this program could be sustainable and even replicable. They have learned to leverage resources between each other’s organizations. For example, CBO partners have gained knowledge on how health centers can access community resources and vice versa. In West Oakland, an F2F mini-grantee, City Slicker Farms, has become a coupon redemption site for WOHC moms. City Slicker Farms also built a garden on the site of the West Oakland Health Council allowing on-going access to a variety of herbs, fruits and vegetables. This demonstrates innovative partnerships around nutrition and food security.
Moreover, F2F has provided an opportunity to build trust between local institutions (CBOs and health centers) bridging existing community assets and social capital. These elements can last beyond the project. Also, F2F builds on partners’ existing strengths and existing project momentum in the food justice and youth development arenas, which points toward sustainability. F2F is funded by the Kresge Foundation through December 2013.SustainabilityThe results of F2F are continually used to inform countywide efforts to improve the health of women, children and families. In addition, we are sharing the results of our model with other communities that seek strategies to increase access to healthy food through the Kresge Foundation online learning-community. Moreover, since this is the first BBC demonstration project we continue to share process results with BBC, which will inform future work of BBC. In addition, they are shared widely with the community through our website and blog.
Through presentations to colleagues in the region and at national conferences, we share our experiences and provide support to other communities working on similar projects. We have presented at UC-Berkeley and the City MatCH conference. F2F is one of six featured ACPHD projects at the annual APHA conference this October. The vast opportunities to share our work will aid F2F to gain local and national recognition and ideally gain continued funding. Moreover, the CBOs and health centers have forged strong relationships with each other and have pledged to continue working together as much as possible communicating F2F both internally amongst their networks and externally through community events. The third year of this project will focus on resource development strategies such as the creation of an enhanced communications and fund development plan at both the ACPHD and partner level.